principles of pediatric and neonatal emergencies, 3rd edition

8/17/2019 Principles of Pediatric and Neonatal Emergencies, 3rd Edition

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Principles of

PEDIATRIC ANDNEONATAL EMERGENCIES


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Principles of

PEDIATRIC ANDNEONATAL EMERGENCIES

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTDNew Delhi St Louis • Panama City • London

®

Third EditionEditors

Panna ChoudhuryPresident IAP, 2009 and Former Senior Consultant

Department of Pediatrics, Lok Nayak Hospital

New Delhi, India

Arvind BaggaProfessor of Pediatrics

Division of Pediatric Nephrology

All India Institute of Medical Sciences

New Delhi, India

Krishan ChughDirector

Center for Child Health, Sir Ganga Ram HospitalDelhi, India

Siddharth RamjiProfessor and Head of Neonatology Unit

Department of Pediatrics, Maulana Azad Medical College

and Associated Lok Nayak Hospital

New Delhi, India

Piyush GuptaEditor-in-Chief, Indian Pediatrics and Professor of Pediatrics

University College of Medical Sciences and GTB HospitalDelhi, India


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Principles of Pediatric and Neonatal Emergencies

© 2011, Indian Pediatrics

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by

any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and

the publisher.

This book has been published in good faith that the material provided by contributors is original. Every effort is made to

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case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 1994

Second Edition: 2004

Third Edition: 2011

ISBN 978-81-8448-950-7

Typeset at JPBMP typesetting unit

Printed at Ajanta Offset


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Contributors

Agarwal Manjari

Clinical Fellow, Pediatric Rheumatologist

Department of Pediatrics, Sir Ganga Ram Hospital

Rajinder Nagar, New Delhi, India

E-mail: [email protected]

Aggarwal Anju

Associate Professor, Department of Pediatrics

University College of Medical Sciences and

Guru Tegh Bahadur Hospital

Delhi, India


Aggarwal Rajiv

Chief Pediatric Intensivist and Neonatologist

Professor and Head, Department of Pediatrics

Narayana Multi-specialty Hospital

858/A, Bommasandra Industrial Area

Anekal Taluk, Bengaluru, Karnataka, India


Aggarwal Satish Kumar

Professor of Pediatric Surgery

Maulana Azad Medical College and

Associated Lok Nayak and GB Pant Hospitals

New Delhi, India

E-mail: [email protected] YK

Former Professor of Pediatrics

Grant Medical College and JJ Group of Hospitals, and

Consultant Pediatrician

Jaslok Hospital and Breach Candy Hospital

Mumbai, India


Aneja S

Director ProfessorDepartment of Pediatrics, Lady Hardinge Medical College

and Kalawati Saran Childrens’ Hospital

New Delhi, India


Arya LS

Senior Consultant

Pediatric Oncology and Hematology

Indraprastha Apollo Hospitals, Sarita Vihar

New Delhi, IndiaE-mail: [email protected]

Aulakh Roosy

Department of Pediatrics, Advanced Pediatric Center

Postgraduate Institute of Medical Education and Research

Chandigarh, Punjab, India

Babu Kishore S

Consultant Pediatric Nephrologist

Department of Nephrology, Manipal Hospital

98, Airport Road

Bengaluru, Karnataka, India


Bagga Arvind

Professor of Pediatrics



New Delhi, India


Bhatia Vidyut

Senior Research AssociateDepartment of Pediatrics


New Delhi, India


Bhatnagar Shinjini

Sr. Scientist-III

Center for Diarrheal Diseases and Nutrition Research

Department of Pediatrics


New Delhi, India


Bhatnagar Shishir


Max Hospital, A-364, Sector 19

Noida, UP, India

Bhatnagar VeereshwarProfessor, Department of Pediatric Surgery


New Delhi, India


Budhiraja Sandeep




Chaturvedi Vivek

Assistant Professor, Department of Cardiology

GB Pant Hospital

New Delhi, India



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Principles of Pediatric and Neonatal Emergenciesvi

Cherian Alice

Professor of Psychiatry

Child and Adolescent Psychiatry Unit

Department of Psychiatry

Christian Medical CollegeVellore, Tamil Nadu, India


Choudhary Sanjay

Pediatrician, BS Ambedkar Hospital

Sector 6, Rohini

Delhi, India


Choudhury Panna

President IAP, 2009 and Former Senior Consultant

Pediatrician, Department of Pediatrics

Lok Nayak Hospital

New Delhi, India


Chugh Krishan

Director, Center for Child Health

Sir Ganga Ram HospitalDelhi, India


Deorari Ashok K

Professor and Incharge, Neonatal Division



New Delhi, India


Dua TarunLecturer, Department of Pediatrics

University College of Medical Sciences and

Guru Tegh Bahadur Hospital

Delhi, India


Dubey AP

Professor and Head

Department of Pediatrics, Maulana Azad Medical CollegeNew Delhi, IndiaE-mail: [email protected]

Dutta Sourabh

Professor, Department of Pediatrics




Ganguly Nupur


Institute of Child Health

Kolkata, West Bengal, India


Gera Tarun

Consultant Pediatrics, Fortis Hospital, Shalimar Bagh

New Delhi, India


Goel Arun

Senior Plastic Surgeon

Department of Burns and Plastic Surgery

Lok Nayak Hospital

Delhi, IndiaE-mail: [email protected]

Gopalan S

Pediatric Gastroenterologist and Executive Director

Centre for Research on Nutrition Support SystemsNutrition Foundation of India Building

C-13 Qutub Institutional Area

New Delhi, India


Gulati Sheffali

Associate Professor

Chief, Division of Child Neurology


All India Institute of Medical SciencesNew Delhi, India


Gupta Dhiren

Consultant, Pediatric Pulmonologist and Intensivist

Department of PediatricsSir Ganga Ram Hospital, Rajinder Nagar

New Delhi, India

[email protected]

Gupta DK

Professor and Head, Department of Pediatric Surgery


New Delhi, India


Gupta Naveen

Clinical Fellow, Division of Neonatology

Children’s and Women’s Health Centre of British Columbia

Vancouver, CanadaE-mail: [email protected]

Gupta Noopur

Senior Research Associate

Dr RP Centre for Ophthalmic Sciences



Gupta Piyush

Editor-in-chief, Indian PediatricsProfessor, Department of Pediatrics

University College of Medical Sciences

Delhi, India



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viiviiviiviiviiContributors vii

Gupta Suresh

Consultant, Pediatric Emergency Medicine

Sir Ganga Ram Hospital

New Delhi, India


Handa KK

Head, Department of ENT

Medanta Medicity

Gurgaon, Haryana, IndiaE-mail: [email protected]

Hari Pankaj

Associate Professor, Division of Nephrology

Department of PediatricsAll India Institute of Medical Sciences

New Delhi, India


Iyengar Arpana

Associate Professor


St. John’s Medical College and Hospital



Iyer Parvathi U

Associate Director, Pediatric Intensive Care

Department of Pediatrics and Congenital Heart Surgery

Escorts Heart Institute and Research Center


Jain Peeyush

Deputy Director, Delhi State AIDS Control Society

11 Lancer’s Road, Timarpur

New Delhi, India


Jain Puneet

Center of Advanced Pediatrics

PGIMER

Chandigarh, India

Janakiraman Lalitha

Senior Consultant, Kanchi Kamakoti Childs Trust HospitalChennai, Tamil Nadu, India


Jayashree M

Additional Professor, Advanced Pediatric Centre




Jhamb UrmilaProfessor, Department of Pediatrics

Maulana Azad Medical College

Delhi, India


Kabra SK



New Delhi, India


Kapoor S

Professor of Orthodontics

Sardar Patel Institute of Dental Sciences

Lucknow, UP, India

Khalil Anita

Former Director Professor, Department of Pediatrics


New Delhi, India


Khanna Neena

Professor, Department of Dermatology


New Delhi, India


Khanna RajeevClinical Assistant

Pediatric Gastroenterologist and Hepatologist




Khilnani Praveen

Senior Consultant

Pediatric Intensivist and Pulmonologist

and Incharge Fellowship Program, Max HospitalsPress Enclave

Saket, New Delhi, India


Kler Neelam

Head and Senior Neonatologist

Department of Neonatology


New Delhi, IndiaE-mail [email protected]

Krishna Anurag

Consultant Pediatric Surgeon and Urologist

Max Institute of Pediatrics and Pediatric Surgery

Max Super-Specialty Hospital

New Delhi, India


Krishnan SAssistant Professor, Pediatric Pulmonology

New York Medical College

New York, USA



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Principles of Pediatric and Neonatal Emergenciesviii

Kulkarni KPSenior Resident, Department of PediatricsIndraprastha Apollo HospitalNew Delhi, India

E-email: [email protected]

Kumar ArunConsultant Neonatal PediatricianMayday University HospitalCroydon, Surrey, United KingdomE-mail: [email protected]

Kumar GirishSenior Resident, Pediatric Intensive CareDepartment of Pediatric and Congenital Heart SurgeryEscorts Heart Institute and Research CenterNew Delhi, IndiaE-mail: [email protected]

Kumar LataFormer Professor and Head, Advanced Pediatric CenterPGIMER, and Consultant Pediatrician1543/Sector 38-BChandigarh, Punjab, IndiaE-mail: [email protected]

Kundu RitabrataProfessor of Pediatric Medicine, Institute of Child Health11, Dr Biresh Guha StreetKolkata, West Bengal, IndiaEmail: [email protected]

Lodha RakeshAssistant Professor, Department of PediatricsAll India Institute of Medical SciencesNew Delhi, IndiaE-mail: [email protected]

Mahadevan SProfessor of PediatricsJawaharlal Institute of Postgraduate MedicalEducation and ResearchPuducherry, IndiaE-mail: [email protected]

Mantan Mukta

Associate Professor, Department of PediatricsMaulana Azad Medical College and Lok Nayak HospitalNew Delhi, IndiaE-mail: [email protected]

Mathew Joseph LAssociate Professor, Department of PediatricsPostgraduate Institute of Medical Education and ResearchChandigarh, Punjab, IndiaE-mail: [email protected]

Mathur NBProfessor, Department of PediatricsMaulana Azad Medical CollegeNew Delhi, IndiaE-mail: [email protected]

Mehta RajeshSenior Pediatrician, Department of PediatricsVardhman Mahavir Medical College andSafdarjang Hospital


Menon PSNConsultant and Head, Department of PediaricsJaber Al-Ahmed Armed Forces Hospital, KuwaitE-mail: [email protected]

Mohan NeelamConsultant Pediatric Gastroenterologist, HepatologistTherapeutic Endoscopist and Liver Transplant Physician

Centre for Child Health, Sir Ganga Ram HospitalNew Delhi, IndiaEmail: [email protected]

Mouli Natchu UC

Ramalingaswami Fellow

Pediatric Biology Centre

Translational Health Science and Technology Institute

496, Udyog Vihar, Phase III

Gurgaon, Haryana, India


Narang AnilFormer Professor and HeadAdvanced Pediatric Center, PGIMERand Head Neonatology, Chaitanya HospitalHospital Site 1 and 2, Sector 44 CChandigarh, Punjab, IndiaE-mail: [email protected]

Narasimhan Ramani

Senior Consultant, Pediatric Orthopedic SurgeonIndraprastha Apollo HospitalsNew Delhi, India


Narayan Sushma

Chief Medical Officer, Kasturba Hospital

Municipal Corporation of Delhi


Patwari AKResearch Professor

International Health Center for Global Health and

Development, Boston University, USA; and

Senior Technical Advisor, MCH- Star Initiative

Upper Ground 4-9, Mohta Building

4, Bhikhaji Cama PalaceNew Delhi, India


Phadke KishoreProfessor, Division of Pediatric Nephrology

St. John’s Medical College and Hospital




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ixixixixixContributors ix

Pooni Puneet A


Dayanand Medical College and Hospital

Ludhiana, Punjab, India


Prajapati BS

Professor, Sheth LG General Hospital

Smt. NHL Municipal Medical College

Ahmedabad, Gujarat, India


Prakash Anand

Fellow Pediatric Hemato-Oncology UnitDepartment of Pediatrics, Sir Ganga Ram Hospital

New Delhi, India


Prakash H

Director-General

ITS Centre for Dental Studies and Research

Delhi Meerut Road, Murad Nagar

Ghaziabad, Uttar Pradesh, IndiaE-mail: [email protected]

Prasad Rajniti

Assistant Professor, Department of Pediatrics

Institute of Medical Sciences, Banaras Hindu University

Varanasi, UP, India

E-mail:[email protected]

Pundhir Pooja

Resident, Department of Obstetrics and GynecologyMaulana Azad Medical College

New Delhi, India


Ramji Siddharth

Professor and Head of the Neonatology Unit

Department of Pediatrics, Maulana Azad Medical College

and Associated Lok Nayak Hospital


Ranjit Suchitra

Consultant, Pediatric Intensive Care

Apollo Hospital, Greams Road

Chennai, Tamil Nadu, India


Rasool Seema B

Research Officer

Department of Dermatology


New Delhi, India


Ray Mily

Fellow, Pediatric Cardiology

Rabindranath Tagore International Institute

of Cardiac Sciences

Kolkata, West Bengal, IndiaE-mail: [email protected]

Rekha Swarna

Professor


St. John’s Medical College Hospital



Russell PSSProfessor of Psychiatry

Child and Adolescent Psychiatry Unit

Department of Psychiatry, Christian Medical College

Vellore, Tamil Nadu, India


Sabharwal RK

Senior Consultant, Child Neurology and Epilepsy

Centre for Child Health, Sir Ganga Ram Hospital



Sachdev Anil

Sr Consultant, Pediatric Pulmonologist

Bronchoscopist and Intensivist, Department of Pediatrics

Sir Ganga Ram Hospital, Rajinder Nagar

New Delhi, India


Sachdev HPS

Senior Consultant Pediatrics and Clinical Epidemiology

Sita Ram Bhartia Institute of Science and Research

B-16, Qutab Institutional Area

New Delhi, India


Sachdeva Anupam

Head, Pediatric Hematology Oncology and BMT Unit

Department of Pediatrics, Sir Ganga Ram HospitalRajinder Nagar, New Delhi, India


Shankar Jhuma


Jawaharlal Institute of Postgraduate Medical

Education and Research

Puducherry, India


Sarthi Manjunatha


SS Institute of Medical Sciences and Research Center

Jnanashankara, Davangere, Karnataka, India



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Principles of Pediatric and Neonatal Emergenciesx

Sawhney Sujata

Consultant Pediatric Rheumatologist




Saxena Anita

Professor, Department of Cardiology


New Delhi, India


Seth Anjali

Consultant Pediatrician, Gouri HospitalDelhi, India


Seth Tulika

Assistant Professor, Department of Hematology


New Delhi, India


Sethi GR

Professor of Pediatrics, Maulana Azad Medical College

New Delhi, India


Shah Dheeraj


University College of Medical Sciences

Delhi, India


Shah Nitin

Consultant Pediatrician, PD Hinduja National Hospital

Mumbai, Maharashtra, India


Sharma Sunil Dutt

Fellow, PICU, Department of Pediatrics

Sir Ganga Ram HospitalRajinder Nagar, New Delhi, India


Shenoi Arvind

Consultant Neonatologist, Head


Manipal Hospital, 98, Airport Road



Singh Daljit


Dayanand Medical College and Hospital



Singh Jaideep

Neonatal Research Fellow

James Cook University Hospital

Middlesbrough, UK


Singh Meenu

Additional Professor and Chief

Pediatric Pulmonology, Advanced Pediatric Center




Singh Sukhmeet


Guru Nanak Hospital



Singh Utpal Kant

Consultant Pediatrician and Associate Professor

Department of Pediatrics, Nalanda Medical College

Patna, Bihar, India


Singh Varinder


Lady Hardinge Medical College and

Kalawati Saran Children’s Hospital

New Delhi, India


Singhal Nitesh

Consultant Pediatric Intensivist, MAX Balaji HospitalIP ExtensionNew Delhi, India


Singhi Pratibha

Professor and Chief

Pediatric Neurology and Neurodevelopment




Singhi Sunit


Chief, Pediatric Emergency and Intensive Care

Advanced Pediatric CentrePostgraduate Institute of Medical Education and Research

Sector 12, Chandigarh, Punjab, India


Sinha AditiSenior Research Associate, Division of Nephrology



New Delhi, India



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xixixixixiContributors xi

Sinha Sunil

Professor of Pediatric and Neonatal Medicine

James Cook University Hospital

Middlesbrough TS4 3BW, UK


Soni Arun

Consultant Neonatologist, Department of Neonatology




Srinivas Murki

Consultant Neonatologist, Fernandez HospitalHyderabad, Andhra Pradesh, India


Srivastava Anshu

Assistant Professor

Department of Pediatric Gastroenterology

Sanjay Gandhi Postgraduate Institute of Medical Sciences

Lucknow, UP, India


Tandon Radhika

Professor of Ophthalmology

Dr RP Centre for Ophthalmic Sciences


New Delhi, India


Taneja Vikas

Fellow Pediatric Critical Care Council (ISCCM)Senior Consultant, Pediatrics

Columbia Asia Hospital, Palam Vihar

Gurgaon, Haryana, India


Tapan Kumar Ghosh

Scientific Coordinator

Institute of Child Health

Kolkata, West Bengal, India

Thavaraj V

Dy. Director General, Senior Grade

Indian Council of Medical Research

Ansari Nagar, New Delhi, India


Tripathi Rewa

Professor, Department of Obstetrics and Gynecology

Maulana Azad Medical CollegeNew Delhi, India


Udani Soonu

Pediatric Intensivist, Section Head, Pediatrics

PD Hinduja Hospital

Mumbai, Maharashtra, India


Upadhyay Amit

Head, Department of Pediatrics

LLRM Medical College

Meerut, UP, India


Vasudevan Anil

Assistant Professor

Division of Pediatric NephrologySt. John’s Medical College and Hospital



Vaswani Jyotsna K

Formerly Senior Resident, Department of Pediatrics


New Delhi, India


Verma Mahesh

Director Principal, Institute of Dental Sciences

Maulana Azad Medical College Complex

New Delhi, India

E-mail: [email protected];

Vijayasekaran D

Assistant Professor and Civil Surgeon

Department of Pulmonology

Institute of Child Health and Hospital for Children

Chennai, Tamil Nadu, India; and

Consultant Pulmonologist

Kanchi Kamakoti Child’s Trust Hospital

Chennai, Tamil Nadu, India


Virmani Anju

Consultant, Pediatric Endocrinologist

Indraprastha Apollo/MAX/Sunder Lal Jain Hospitals

New Delhi, India


Yachha Surender K

Professor, Department of Pediatric Gasteroenterology

Sanjay Gandhi Postgraduate Institute of Medical Sciences

Lucknow, UP, India


Yadav Satya P

Consultant Pediatric Hemato-Oncology Unit

Department of Pediatics, Sir Ganga Ram HospitalNew Delhi, India



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Foreword

The subspecialty of Pediatric and Neonatal Emergencies has seen tremendous growthin the last few years. This is one field where the treating physician is running againsttime. The timely treatment is vital for intact survival of sufferers.

The Indian Pediatrics Book Principles of Pediatric and Neonatal Emergencies hasaddressed this issue very well in its last two issues. There is a need to improve theunderstanding about the very basic behind handling these emergencies. The thirdedition of this book published by Jaypee Brothers Medical Publishers (P) Ltd, NewDelhi, India has included recent developments in this field.

Contributors of this book are well-known experts from respective subspecialties andfrom various parts of our country. Editor-in-Chief, Dr Panna Choudhury, has done agreat job in putting together all articles in a common editorial style. I congratulate othereditors Dr Arvind Bagga, Dr Krishan Chugh, Dr Siddarth Ramji and Dr Piyush Guptaalso in bringing out this book which covers all aspects of emergency pediatrics. There is a good combinationof evidence and experience in dealing with all topics included in this book.

The book is written to be relevant to the needs of the hour. It is reasonably detailed and is a good blendof latest developments in the management approach in various pediatric and neonatal emergencies within theconstraints of resources and equipment faced at most of the places.

I am sure this book will fulfill all needs of both, the practicing pediatricians and postgraduate students indealing with emergencies.

Deepak Ugra MDConsultant Pediatrician

Lilavati Hospital and Research Centre, MumbaiPresident, Indian Academy of Pediatrics – 2010


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Preface to the Third Edition

We are happy to present the third edition of Principles of Pediatric and Neonatal Emergencies. The present editioncontinues with its tradition of serving the needs of physicians involved in the immediate care of children andneonates with life-threatening illnesses. The book has been extensively revised and updated, to reflect thecurrent standards of emergency care relevant to the needs of pediatricians working in developing countries.

This book continues to have the privilege of scholarly writings from illustrious authors, across the country.We welcome several new colleagues and express gratitude for their contributions to this edition. A numberof chapters have been completely rewritten, including those on hematological disorders, upper gastrointestinal

bleeding, neonatal surgical disorders, and ophthalmologic emergencies. Inputs from consensus and expertstatements of the Academy have been incorporated for management of malaria and severe malnutrition. Theemphasis continues to be on presenting management of common and important emergencies affecting children.Detailed discussions on pathophysiology have been avoided.

We hope that this text shall continue to serve the needs of pediatricians, physicians, resident doctors, othertrainees and be a part of all pediatric emergency units. As before, all the royalties generated from the sale of the book shall pass onto the journal, Indian Pediatrics.

Finally, we thank Mr RG Bhardwaj and Ms Veena Arora for secretarial assistance and are grateful toM/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India for their guidance and expeditiouspublication.

Panna ChaudhuryArvind Bagga

Krishan ChughNew Delhi Siddharth Ramji

January 2011 Piyush Gupta


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Preface to the First Edition

For the practitioners of pediatric care, emergencies in children and neonates are an inescapable fact in theirdaily routine. Better understanding of pathophysiology and drug metabolism and availability of newerinvestigative and diagnostic facilities have led to the creation of new frontiers in this important subject. Promptrecognition and appropriate management of these emergencies make the difference between life and death. Avariety of traditional western textbooks provide information on this topic. However, this updated knowledgeis often not relevant for the developing world situation.

Inspired by the success of its earlier venture titled Pediatric and Neonatal Emergencies, Indian Pediatrics—theofficial journal of the Indian Academy of Pediatrics, took up the formidable challenge of providingcomprehensive state-of-the-art information on the subject which would also be pertinent in the Indian milieu.The present publication has been extensively updated and enlarged from the earlier experiment which nowappears like a distant cousin. Guidelines have also been incorporated for organization of pediatric intensivecare units.

We are indebted to the group of distinguished contributors who promptly responded to our call, despiteconstraints of their busy schedules.

This volume is intended for pediatricians and physicians sharing initial contact with emergencies in childrenand neonates as well as those responsible for the subsequent critical and intensive care. Postgraduate studentsshould find it of particular help. The book should also prove invaluable for all current and intended pediatricemergency care units.

The editors share of financial benefits from the royalties would accrue to the Indian Pediatrics in an attemptto make the journal self-sufficient. We are grateful to the publishers for ensuring the high quality of the bookas well as its expeditious publication.

This volume is dedicated to the memory of late Dr Man Mohan, an active associate in the earlier venture.

HPS SachdevRK Puri

New Delhi A BaggaFebruary, 1994 P Choudhury


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Contents

Section 1: Organization of Emergency Department

1. Approach to Child in Emergency Department ............................................... ................................................ 3Krishan Chugh

Pediatrician’s Contact with the Sick Child 3Age-related Approach 4The Complete Physical Examination 4Identification of an Acutely Ill Child 5CPR in Emergency Department 6The Death of a Child in the Emergency Department 6

2. Ethical and Legal Issues in Emergency Care .................................................................................................. 9Krishan Chugh

Ethics 9

Legal Responsibilities 9Types of Legal Risks 9Legal Risk factors 10Legal and Ethical Issues in Consent 10Ethical and Legal Issues in Training and Research 11Ethical and Legal Issues in CPR 11Ethical and Legal Issues in withholding Life Support 12Ethical and Legal Issues in Death 12Hospital Ethics Committees 12

The Medical Record 12Steps for Suit Prevention 12

3. Organization of Pediatric Emergency Services ............................................................................................ 14Krishan Chugh

Pediatric Emergency Service in a General/Pediatric Hospital 14Pediatric Emergency Services in the Clinic 15Physical Design of Emergency Department 15Computers in the Emergency Department 20

Cost of Emergency Care 20

Section 2: Resuscitation and Life-threatening Emergencies

4. Emergency Airway Management and Cardiopulmonary Resuscitation ................................................. 25S Krishnan, Sunil Dutt Sharma

Pediatric Tachycardia with Pulses and Poor Perfusion 49Pediatric Tachycardia with Pulses and Adequate Perfusion 49

5. Oxygen Therapy ................................................ ..................................................... ............................................ 52Soonu Udani


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Principles of Pediatric and Neonatal Emergenciesxx

6. Shock ............................................ ................................................. ............................................... ........................ 57Sunit Singhi, Puneet Jain

Correction of Metabolic Abnormalities 67

Newer Modalities for Sepsis and Septic Shock 707. Respiratory Failure ............................................................................................................................................ 74

Praveen Khilnani, Nitesh Singhal

8. Anaphylaxis ........................................................................................................................................................ 84 Anil Sachdev

Section 3: Pediatric Medical Emergencies

9. Acute Asthma ..................................................................................................................................................... 93GR Sethi

Step 1: Initial Assessment of Severity 93Step 2: Initiation of Therapy 94Step 3: Assessment of Response to Initial Therapy 99Step 4: Modification of Therapy for patients with Partial and Poor Response to Initial Therapy 99

10. Stridor ................................................................................................................................................................ 107

Meenu Singh, Sandeep Budhiraja, Lata KumarPathophysiology 107Assessment of a Child with Stridor 110Treatment 111Prognosis 113

11. Lower Respiratory Tract Infection.................................................. .................................................... .......... 117D Vijayasekaran

Acute Lower Respiratory Tract Infection 117

Laryngotracheobronchitis (Croup) 118Bronchiolitis 118Pneumonia 119

12. Heart Failure ..................................................................................................................................................... 123Vivek Chaturvedi, Anita Saxena

Introduction 123Causes of Heart Failure in Infants and Children 123Epidemiology of Heart Failure 125

Clinical Features 125Investigations 127Management of Heart Failure 130

13. Cardiac Arrhythmias ....................................................................................................................................... 140 Anita Khalil, Jyotsna K Vaswani

14. Hypertensive Emergencies ................................................ ................................................. ............................ 152 Aditi Sinha, Pankaj Hari

15. Acute Renal Failure ......................................................................................................................................... 158 Arvind Bagga, Mukta Mantan

Nomenclature and Classification 158Biomarkers 159Neonatal ARF 159

i


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xxixxixxixxixxiContents xxi

Causes of ARF 159

Clinical Features 161Diagnostic Approach to ARF 161Management of ARF 162

Outcome 167

16. Fluid and Electrolyte Disturbances .............................................................................................................. 169Rakesh Lodha, Manjunatha Sarthi, Natchu UC Mouli

Physiology 169Disorders of Sodium Homeostasis 172Disorders of Potassium Homeostasis 177

17. Acid-Base Disturbance ................................................................................................................................... 182

Rakesh Lodha, Manjunatha Sarthi, Arvind BaggaPhysiology 182Acid Elimination and Compensation 183Acid-base Disorders 183

18. Hematuria.......................................................................................................................................................... 192

Anil Vasudevan, Arpana Iyengar, Kishore Phadke

Categorizing the Patient with Hematuria 192Evaluating a Child with Hematuria 193

Management 195

19. Acute Seizure ................................................ ................................................. ................................................... 197Tarun Dua, Piyush Gupta

20. Approach to a Comatose Patient ................................................................................................................... 205Suchitra Ranjit

Guidelines for Differentiating Causes of Coma 205Evaluation of a Child in Coma 205

Laboratory Evaluation 208Management of a Comatose Patient 208

Prognosis 210

21. Intracranial Hypertension ................................................. ................................................. ............................ 211Pratibha Singhi, Roosy Aulakh, Sunit Singhi

Pathophysiology 211

Management of Raised Intracranial Hypertension 215

22. Acute Flaccid Paralysis ................................................................................................................................... 224RK Sabharwal

Clinical Approach 224

23. Acute Bacterial Meningitis............................................................................................................................. 237S Aneja, Anju Aggarwal

Epidemiology 237Etiology 237Pathogenesis and Pathology 237

Clinical Features 238Complications 238Differential Diagnosis 241

Treatment 241Antibiotic Therapy 241

P i i l f P di t i d N t l E iii


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Principles of Pediatric and Neonatal Emergenciesxxii

Prognosis 243Prevention 244

24. Encephalitis....................................................................................................................................................... 248

Sheffali GulatiEtiology 248Epidemiology 248Pathogenesis 248

25. Acute Diarrhea and Dehydration ................................................................................................................. 258 AK Patwari

Diarrheal Dehydration 258Compensatory Mechanisms 258

Clinical Features 259Case Management 259Assessment of Dehydration 259Oral Rehydration Therapy 261ORS in Neonates 261Intravenous Fluid Therapy 261Rehydration of Severely Malnourished Children 262Electrolyte Disturbances 262

26. Acute Liver Failure .......................................................................................................................................... 266Neelam Mohan, Rajeev Khanna

Introduction 266Definitions 266Etiology 266Clinical Features 267Orthotopic Liver Transplantation 272

27. Upper Gastrointestinal Bleeding ............................................................... ................................................. .. 275

Anshu Srivastava, Surender K YachhaEtiology 275Clinical features 276Endoscopic therapy 280Treatment 282

28. Hematologic Emergencies ................................................. ................................................. ............................ 285Tulika Seth

Bleeding Child 285

Disseminated Intravascular Coagulation 291Depression of Bone Marrow Activity 294Blood Transfusion Reactions 295Hemolysis 296Sickle Cell Disease 299Thrombosis 301

29. Oncologic Emergencies................................................................................................................................... 305LS Arya, V Thavaraj, KP Kulkarni

Oncological Emergencies Due to Structural or Local Effects of Tumor 305Abnormalities of Blood and Blood Vessels 308Metabolic Emergencies 309Oncological Emergencies Secondary to Treatment Effects 311

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xxiiixxiiixxiiixxiiixxiiiContents xxiii

30. Blood Component Therapy ................................................... ........................................................ ................. 314 Anupam Sachdeva, Satya P Yadav, Anand Prakash

Appropriate Use of Blood and Blood Products 314Whole Blood 314Red Blood Cells 315Plasma 320Platelets 322Granulocytes 324Cryoprecipitate 325

31. Diabetic Ketoacidosis ..................................................................................................................................... 329 Anju Virmani, PSN Menon

32. Other Endocrine Emergencies ....................................................................................................................... 336 Anju Virmani

Adrenal Crisis 336Thyroid Storm (Accelerated Hyperthyroidism) 338Congenital Hypothyroidism 339

33. Calcium Metabolic Emergencies................................................................................................................... 340BS Prajapati, Anju Virmani

Hypocalcemia 340

Hypercalcemia 342

34. Management of Severely Malnourished Children ............................................ ........................................ 344Shinjini Bhatnagar, Rakesh Lodha, Panna Choudhury, HPS Sachdev, Nitin Shah, Sushma Narayan

35. Malaria .......................................... ................................................. ................................................... ................. 359Ritabrata Kundu, Nupur Ganguly, Tapan Kumar Ghosh

Artemesinin Combination Therapy 359Uncomplicated Malaria 359

Severe and Complicated Malaria 359Supportive Management 360Management of Complications of Malaria 363

36. Dengue Hemorrhagic Fever and Dengue Shock Syndrome .......................................... .......................... 364SK Kabra, Rakesh Lodha

Clinical Manifestations 364Grading of DHF 365Diagnosis 365Laboratory Investigations 366Treatment 366Monitoring 368Prognosis 368

37. Fever without a Focus...................................................................................................................................... 370YK Amdekar

Rule Out Serious Illness 371Agewise Diagnostic Approach 372

38. Dermatologic Emergencies ............................................................................................................................ 374Neena Khanna, Seema B Rasool

Acute Urticaria and Angioedema 374Epidermal Necrolysis 375

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Principles of Pediatric and Neonatal Emergenciesxxiv

Staphylococcal Scalded Skin Syndrome (SSSS) 377Erythroderma 377Collodion Baby 378Drug Eruptions 379

Pemphigus 379Epidermolysis Bullosa (EB) 380Herpes Virus Simplex Infections 382Erysipelas and Cellulitis 382

39. Gynecologic Emergencies .............................................................................................................................. 384Reva Tripathi, Pooja Pundhir

Foreign Body in Genital Tract 384Direct Trauma to Vagina—Tears and Lacerations 384

Puberty Menorrhagia 386Imperforate Hymen, Transverse Vaginal Septum 387Twisted Ovarian Cyst 388Teenage Pregnancy Complications 388

40. Psychiatric Emergencies ................................................................................................................................. 390PSS Russell, Alice Cherian

Basic Principles and Decision Making in Emergency Psychiatry 390Epidemiology 390

Classification of Psychiatric Emergencies in Infants and Toddlers, Children and Adolescents 39041. Emergencies in Pediatric Rheumatology .......................................... .................................................. ......... 399

Sujata Sawhney, Manjari Agarwal

Introduction 399 Juvenile Idiopathic Arthritis (JIA) 399Antiphospholipid Antibody Syndrome 401 Juvenile Dermatomyositis (JDM) 403

Section 4: Environmental Problems

42. Burns .................................................................................................................................................................. 409 Arun Goel, Urmila Jhamb

Mode of Injury 409Prevention 410First Aid 410Hospital Management 410

43. Drowning .......................................................................................................................................................... 420Lalitha Janakiraman

Pathophysiology 420

44. Heat Illnesses.................................................................................................................................................... 426Dheeraj Shah, HPS Sachdev

45. Electric Shock ................................................................................................................................................... 434Piyush Gupta, Mily Ray

46. Snake Bite.......................................................................................................................................................... 439 Joseph L Mathew, Tarun Gera

Management of Ophitoxemia 442

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xxvxxvxxvxxvxxvCo te ts xxv

47. Scorpion Envenomation ................................................................................................................................. 445S Mahadevan, Jhuma Shankar

Case Vignettes 445The Problem 445Distribution 445Pathophysiology 445Venom 445Effect of the Venom on Various Tissues/Organs 446

Section 5: Toxicological Emergencies

48. General Management of a Poisoned Child ............................................. .................................................. .. 457

Suresh Gupta, Vikas Taneja

49. Management of Specific Toxicological Emergencies ......................................... ....................................... 465Vikas Taneja, Krishan Chugh, Sanjay Choudhary, Utpal Kant Singh, Rajniti Prasad, Puneet A Pooni,Daljit Singh, Tarun Dua, Rajesh Mehta, S Gopalan, Panna Choudhury

49.1 Hydrocarbon (Kerosene) Poisoning .................................................... .............................................. 465Vikas Taneja, Krishan Chugh

49.2 Dhatura .............................................. ............................................... .................................................. .... 469

Sanjay Choudhary49.3 Opioids ............................................... ................................................. ............................................... .... 471

Sanjay Choudhary

49.4 Acetaminophen Poisoning ............................................................... ................................................. .. 474Utpal Kant Singh, Rajniti Prasad

49.5 Organophosphorus Poisoning ........................................... ................................................. ............... 478Puneet A Pooni, Daljit Singh

49.6 Lead Poisoning ............................................... ..................................................... .................................. 484Tarun Dua

49.7 Iron Poisoning ................................................... ..................................................... ............................... 489Utpal Kant Singh, Rajniti Prasad

49.8 Barbiturate Poisoning ................................................ ................................................. ......................... 494Rajesh Mehta

49.9 Phenothiazine Toxicity ............................................... ................................................. ........................ 496Rajesh Mehta

49.10 Corrosive Poisoning ................................................ ................................................. ............................ 497S Gopalan, Panna Choudhury

49.11 Naphthalene Poisoning .............................................. .................................................. ....................... 500S Gopalan, Panna Choudhury

Section 6: Neonatal Emergencies

50. Neonatal Emergencies in Delivery Room ................................................................................................... 503 Amit Upadhyay, Ashok K Deorari

Neonatal Emergencies which can Present in Labor Room 503Management of Neonatal Emergencies 504

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Baby not Breathing at Birth 504Technique of Chest Compression 508Use of Drugs 508When to Stop Resuscitation withhold Resuscitation 509

Meconium Stained Liquor 509Shock 510Drug Depression 510Hydrops Fetalis 510Impaired Lung Function 511Accidental Injection of Local Anesthetic 512Airway Anomalies in Delivery Room Resuscitation 512

51. Approach to a Sick Newborn......................................................................................................................... 515

Siddharth RamjiInitial Assessment 515Emergency Triage 516Differential Diagnosis 517Breastfeeding Problems Presenting in the Emergency Room 518

52. Respiratory Failure in Newborn ................................................................................................................... 520 Jaideep Singh, Sunil Sinha

Causes of Respiratory Failure in the Newborn 520

Mechanisms of Respiratory Failure 521Assessment of Respiratory Failure 521Treatment of Respiratory Failure 522Mechanical Ventilation 524Management of Specific Respiratory Conditions 525

53. Shock in the Newborn .................................................................................................................................... 530Rajiv Aggarwal

Definition 530

Tissue Perfusion and Shock 530Blood Pressure and Shock 530Etiology of Shock 531Stages of Shock 532Monitoring for Physical Signs 532Initial Management of Shock 532Issues in Fluid Resuscitation 533Refractory Shock 534Afterload Reduction 535Management of Complications 535

54. Neonatal Convulsions ........................................... ................................................. ......................................... 538Swarna Rekha

Incidence 538Etiology of Neonatal Convulsions 538Classification of Neonatal Convulsions 538Clinical Approach 539Management of Neonatal Convulsions 540Why Should Seizures be Treated? 541

When to Treat Seizures? 541Adequacy of treatment 541Choice of Anticonvulsant 541Refractory Seizures 542

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Second Line Anticonvulsants 542Newer Antiepileptic Drugs 543Neonatal Status Epilepticus 543Special Situations 543

Seizure Control—Clinical or EEG Control 543Duration of Anticonvulsant Therapy 544Prognosis 544

55. Neonatal Hypoglycemia ................................................................................................................................. 546Sourabh Dutta

Glucose Homeostasis and Metabolic Adaptation at Birth 546Causes of Hypoglycemia 547Hypoglycemia and the Brain 549

Definition of Hypoglycemia 550Prevention of Hypoglycemia 552Treatment of Hypoglycemia 553Methods of Measuring Blood or Plasma Glucose 554

56. Neonatal Jaundice ............................................. .................................................. ........................................... .. 557Srinivas Murki, Anil Narang

Bilirubin Metabolism and Etiology of Jaundice 557Clinical Evaluation of a Jaundiced Neonate 558

Prediction of Severe Jaundice 559Investigations 561Treatment of Severe Jaundice 561Intravenous Immunoglobulin 564

57. Management of the Bleeding Neonate ........................................................................................................ 569 Arun Kumar

Major Causes of Bleeding 569Hemorrhage in the Perinatal Period 572Iatrogenic 572Sites of Major Hemorrhage 572Gastrointestinal Hemorrhage 573Intra-abdominal Bleeding 573Subgaleal Hemorrhage 573Intracranial Hemorrhage 573Bleeding from the Umbilical Cord 574Approach to a Child with Bleeding 574Emergency Management 575Subsequent Management 576Prevention 576

58. Neonatal Cardiac Emergencies .............................................. ................................................. ....................... 579Girish Kumar, Parvathi U Iyer

Magnitude of the Problem 579Clinical Presentation 579Emergency Management and Initial Stabilization 586

59. Acute Kidney Injury in Newborn ......................................................... ..................................................... ... 591

Arvind Shenoi, S Kishore BabuIntroduction 591Physiology 591Definitions of AKI 591

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Definition 591Incidence 592Causes of Neonatal AKI 592Pathophysiology of ATN 593

Clinical Approach 594Management 595Bioartificial Kidney and Bioengineered Membranes in AKI 597Drugs in Renal Failure 597Recent Trends in ARF Therapy 597Stem cell therapy in AKI 597Management of the Diuretic Phase 598Prognosis 598

60. Disturbances in Temperature in Newborn .................................................... ............................................. 600NB Mathur

Mechanisms of Heat Loss 600Response to Cold Stress 600Risk Factors for Hypothermia 602Severity of Hypothermia: WHO Classification 602Measuring or Assessing the Newborn’s Temperature 602Effects and Signs of Hypothermia 602Management of Hypothermia in Hospital 603

Duration of Rewarming 603Kangaroo Mother Care 604Management at Home 604Warm Chain 604Hyperthermia 604Physiological Response to Hyperthermia 604Causes of Hyperthermia 605Symptoms of Hyperthermia 605Management 605

61. Neonatal Surgical Emergencies .............................................. ................................................. ...................... 607Satish Kumar Aggarwal

Introduction 607Neonatal Intestinal Obstruction 607Abdominal Wall Defects 620Surgical Causes of Respiratory Distress in the Newborn 622Posterior Urethral Valves (PUV) 628Antenatal Hydronephrosis 629

62. Neonatal Transport ............................................. ................................................. ............................................ 632Neelam Kler, Arun Soni, Naveen Gupta

Introduction 632Why is Transport of Sick Patients Necessary? 632Clinical Presentation of Transported Babies 632Types of Transport 633Regionalization of Neonatal Health Care Facilities 633Whom to Transport 634Where to Transport 634

Mode of Transport 634Transport Personnel 635Leadership 635Team members 635Transport Equipment 636

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Specific Equipment Items 636CPAP Devices 636Incubators 637Principles of Transport 637

Modules for Transport 638Complications of Transport 638Family Counseling 640Cost of Transport 640Aviation Physiology in Neonatal Transport 640

Section 7: Pediatric Surgical Emergencies

63. Acute Abdomen ............................................................................................................................................... 645Shinjini Bhatnagar, Veereshwar Bhatnagar, Vidyut Bhatia

Introduction 645Evaluation of the Child with Acute Abdomen 645Classification of Etiologies 647Location of Underlying Cause 648Emergency Investigations 652Principles of Management 653

64. Urological Emergencies .................................................................................................................................. 655

Anurag Krishna

Urinary Tract Injuries 655Retention of Urine 655Urosepsis 656Acute Scrotum 656

65. Pediatric Trauma ................................................. ..................................................... ........................................ 658Peeyush Jain, AP Dubey

Major Trauma 658Spectrum of Trauma 658Trauma Scores 660Head Trauma 661Minor Trauma and Lacerations 662

66. Orthopedic Emergencies ................................................................................................................................ 666Ramani Narasimhan

Immature Skeleton—Basic 666

Physes or ‘Growth Plate’ 666General Approach 667Pediatric Orthopedic Trauma 668Fractures and Dislocations of Upper Limb 668‘Pulled Elbow’ 670

67. Ocular Emergencies ............................................ .................................................. ........................................... 683Radhika Tandon, Noopur Gupta

68. Ear, Nose and Throat Emergencies ............................................. .................................................. ................ 690KK Handa

Ear 690Nose 691Throat 692

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69. Oral and Dental Emergencies ............................................... ................................................. ........................ 693 H Parkash, S Kapoor, Mahesh Verma

Section 8: Pediatric Emergency Procedures

70. Procedures in Emergency Room ................................................................................................................... 703 Anil Sachdev, Dhiren Gupta, Daljit Singh, Puneet A Pooni, M Jayashree, Varinder Singh,Shishir Bhatnagar, Sukhmeet Singh, DK Gupta, Tarun Gera, Anjali Seth

70.1 Sedation, Analgesia, Anesthesia ................................................................ ....................................... 703 Anil Sachdev

Introduction 703Pre-evaluation 704Assessment Tools 704Monitoring 705Specific Drugs 705

70.2 Pulse Oximetry .............................................. ..................................................... ................................... 709Dhiren Gupta

70.3 Non-invasive Blood Pressure Measurement ............................................ ....................................... 713

Dhiren Gupta

70.4 Intramuscular Injections ............................................... ................................................. ..................... 718Daljit Singh, Puneet A Pooni

70.5 Intravenous Infusion ................................................ ................................................. .......................... 719Daljit Singh, Puneet A Pooni

70.6 Vascular Access ........................................... ................................................. ......................................... 720 M Jayashree

Cannulation of Peripheral Veins 720Factors that Increase the Risk of Arterial Catheter Thrombosis 726

70.7 Venous Cut Down .................................................. ................................................. ............................. 727 Anil Sachdev

70.8 Lumbar Puncture .......................................... ................................................. ....................................... 728Varinder Singh, Shishir Bhatnagar

70.9 Abdominal Paracentesis .............................................. ................................................. ....................... 728Varinder Singh, Shishir Bhatnagar

70.10 Pericardiocentesis ........................................... .............................................. ........................................ 729 Anil Sachdev

70.11 Thoracocentesis/Pleural Tap ............................................ ................................................. ................. 730Varinder Singh, Shishir Bhatnagar

70.12 Tube Thoracotomy and Needle Decompression ...................................................................... ...... 731

Varinder Singh, Shishir Bhatnagar70.13 Cervical Spine Stabilization in Trauma ................................................... ........................................ 732

Sukhmeet Singh

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70.14 Heimlich Maneuver ................................................. ................................................. ........................... 733Sukhmeet Singh

70.15 Insertion of Nasogastric Tube ................................................... ................................................. ........ 736

Daljit Singh, Puneet A Pooni70.16 Urinary Bladder Catheterization ............................................................... ........................................ 737

DK Gupta

70.17 Suprapubic Tap.......................................... ................................................. .......................................... 737Daljit Singh, Puneet A Pooni

70.18 Hydrostatic Reduction of Intussusception ..................................................................................... . 738DK Gupta

70.19 Tracheostomy ............................................ ................................................. ........................................... 738Tarun Gera, Anjali Seth

ANNEXURES.................................................................................................................................................... 743

Annexure 1: Dosages of Some Common Drugs ......................................................... ............................ 745 Ashok K Deorari, Rakesh Lodha

Annexure 2: Reference Laboratory Values ............................................................................................. 769

Tarun Gera

I nd ex .................................................. ..................................................... ................................................. ........... 775


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Emergency Department


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PEDIATRICIAN’S CONTACTWITH THE SICK CHILD

The anxious family members bring children to thephysician as soon as they perceive that the child has aserious illness or injury. The physician or thepediatrician may be in a sophisticated, well equippedand well managed pediatric hospital, in a generalhospital, a small nursing home or just an outpatientfacility — the pediatrician’s office or clinic. No matterwhere he is the responsibilities of the pediatrician go

far beyond just providing the immediate medicalattention to the sick child. Many a times, the family istotally unaware about the illness of the child or its trueseriousness because the child may only be cryinginconsolably or conversely be very lethargic. The infantmay not be able to communicate at all to the parentsand their anxiety, and often guilt, create a situationwhere by the “family is the patient”and not just thechild. At such a time the pediatrician has to give alook of confidence and competence whilesimultaneously showing understanding and empathy.Hence, the importance of initial encounter of thepediatrician with the sick child and his family cannot

be over emphasized.The pediatrician has to understand the anxieties and

fears of sick children and their families when theycome to him (Table 1.1). The fears of the parents and

the family may be different from that of the child. Hehas to formulate an approach to the child and thefamily taking into consideration those factors withinthe limits of the time and facilities available. Thefollowing basic principles facilitate the examination andtreatment of the sick children:1,2

1. Remain calm and confident.

2. Establish rapport with the parent and the child.

3. Be direct and honest.4. Do not separate the parent and the child.

5. Make as many observations as possible withouttouching the child.

6. Be flexible in the order and method of examination.It is not absolutely necessary to examine the childin the order taught in undergraduate teaching days.The information gathered in any practical way canlater on be synthesized into a systematic outline.

7. Examination that produces pain or discomfortshould be performed last of all, e.g. examination of throat with a spatula or examination of ears.

8. Keep the child and care taker informed.9. Be kind and provide feedback and reassurance.

When applying these principles to an Indian context,the family scenario of “elders” accompanying the childmust be taken into account. It must be rememberedthat often they and not the parents of the child aredecision makers. Similarly, the importance of anindividual who spends maximum time with the childas a caregiver should not be forgotten when elicitinga history.

Table 1.1: Fears of the family and the childFears of the family

1. Fear of death of the child

2. Fear of serious illness

3. Fear of incurable illness

4. Fear of the unknown: What next?

5. Fear of separation of child for examination/

procedure/treatment

6. Fear of unknown and possibly not fully competent staff

caring for the child7. Fear of unfamiliar environment

8. Fear of machines/instruments

9. Fear of being told “sickness is because of your

negligence”

10. Fear of economic loss because of child’s illness

Fears of the child (are age dependent)

1. Stranger anxiety

2. Separation from parents3. Pain4. Fear of the unknown

5. Fear of unfamiliar environment

Approach to Child in

Emergency DepartmentKrishan Chugh

1

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AGE-RELATED APPROACH

Optimum physical examination of an infant or childrequires his co-operation. At least, he should not becrying and struggling. Hence, all efforts should bemade to gain the confidence and trust of the child. Thefew minutes required for this purpose maynot be available in a critically ill patient in whommeasures for resuscitation must be institutedimmediately.3

While every pediatrician develops his own methodsand “tricks” for overcoming the initial resistance of thechild, some general recommendations can be made.

These techniques are based on an understanding of theage-related fears and the important developmentalissues at that age. This developmental approach topediatric emergency patient (Table 1.2) has been foundquite useful.

Pre-school children are generally the most difficultpatients. Their fears of separation and pain areparticularly strong. However, they can be won over

by encouraging fantasy, play and participation in

examination. Simple explanation of the procedure being performed is helpful. School age children wantto participate in their own care. Thus, they should begiven choices. For example, when auscultating chest,the child may be asked whether he would preferexamination lying down or sitting. Each step must beexplained to them and then their co-operation can besought more easily.

In contrast to these age groups, the two extremes of pediatric age groups are easier to examine. For neonates,a comfortable environment and warm hand are all thatis required. Over the next few months the infants can

be engaged by sounds produced by the examiner orsome bright colored objects or toys shown to them.Similarly, adolescents do not offer any difficulty inexamination provided they are assured of confidentialityand autonomy. Respect for their privacy must be fullyhonored. If the pediatrician’s gender is not same as thatof the adolescent, it may be a good idea to have aparaclinical worker or a colleague of the adolescentpatient’s gender to be inside the examination room.Choice of having the parents inside should be left tothe adolescent patient.

At all other ages it is preferable to have the parents/caregivers around when the patient is being examined.In fact, as much of the examination as possible should

be performed with the child in the mother’s custody.At times it may become necessary to examine a restlesschild when being given breast feed. For this, it is our

duty to provide privacy to the mother.

THE COMPLETE PHYSICAL EXAMINATION

The importance of a complete head to toe examinationin the emergency room must be appreciated by allthose working there (Table 1.3). This is true even whenan obvious diagnosis has been made and the patientis apparently improving on the immediate treatment

Table 1.2: Development approach to pediatric emergency patient

Age Important development issues Fears Useful techniques

Infancy Minimal language: Feel an extension of parents, Stranger Keep parents in sight and touch,

0-1 sensitive to physical environment anxiety avoid hunger, use warm hands,

keep room warm

Toddler Receptive language more Brief Maintain verbal communication,

1-3 advanced than expressive, see separation examine in parent’s lap, allowthemselves as individuals, assertive will pain some choices when possible

Pre-school Excellent expressive skills for Long separation Allow expression, encourage

3-5 thoughts and feelings ,rich fantasy life, pain fantasy and play, encourage

magical thinking, strong concept of self participation in care

School age Fully developed language, understanding Disfigurement Explain procedures, explain

5-10 of body structure and function, able to loss of function pathophysiology and treatment ,

reason and compromise experience death project positive outcome,

with self control, incomplete understanding of stress child’s ability to master

death situation, respect physical modestyAdolescence Self–determination decision making, peer Loss of autonomy Allow choices and control stress

10-19 group important, realistic view of death loss of peer acceptance by peers, respectacceptance, death autonomy, stress confidentiality

55555

Approach to Child in Emergency Department 5

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provided. For example, a toddler has been brought forhigh fever and irritability. On examination clearevidence of upper respiratory tract infection is found.Antipyretics (which also have analgesic effects) aregiven along with tepid sponging. Child’s fever comesdown. He is not restless any more and is sent home.Such a child is likely to return back if the associated

acute otitis media was missed.In the same context, unclothing the child is an

important step to facilitate examination of the coveredareas, especially the genitalia. Again, for such anexamination, especially for adolescents, adequateprivacy must be provided.

There is a general tendency of the parents to overclothe their young children, more so during wintermonths. This could hinder optimum examination of even the chest or the abdomen.

A 6 months old child was brought to the casualtydepartment for fever and excessive crying. He had‘neck-stiffness‘. All arrangements for performing alumbar puncture were made. Child’s high-neckpullover was removed for doing the lumbar punctureand he suddenly stopped crying and became cheerful.Gone was his ‘neck-stiffness‘.

Many a times a complete examination is not possibleduring the first attempt. The child may be uncooperativeor he may be having a problem that needs immediateattention, e.g. a convulsing child. Obviously, thepediatrician must return to this patient at anotherappropriate occasion to complete the examination.

There are other occasions when a completeexamination has indeed been performed but a re-checkafter a few minutes may be necessary. For example, a

child may have apparent tachycardia with fever raisingdoubts about say myocarditis. One hour later when hisfever has been controlled tachycardia may settle downcompletely. Thus, repeated examinations may berequired in some children to get the complete picture.

IDENTIFICATION OF AN ACUTELY ILL CHILD

Experience as well as statistics show that a large numberof patients coming to the emergency department do nothave any life-threatening problem. Afterall, unlike thepediatric intensive care units (PICUs), emergencydepartments (EDs) are for sick or injured children andnot necessarily for dying children. However, this attimes puts the personnel of the ED into ‘complacency’.They may fail to respond with appropriate speed andurgency when a patient requiring say cardiopulmonaryresuscitation, arrives in the ED. Thus, it is important totrain all those involved in the care of acutely sick

children to recognize life-threatening situations.To identify an acute emergency the pediatrician has

his usual tools of history taking, observation of thechild’s behavior, physical examination, bedsidemonitors and judicious use of laboratory parameters.These when collated together and analyzed may enablethe pediatrician to institute appropriate therapeuticmeasures. At times those results may prompt him toperform or prescribe further tests or ask more questions

in the history. Thus, dilated pupils in a child withinappropriate behavior would call for taking historyabout possible dhatura poisoning.

Change in behavior of the child or his response tostimuli given by the parents or the examiner duringan examination and observation period can provideimportant clues to the overall degree of sickness of thechild. Consolability of a child who is irritable is anexample. If the child who was crying and fussing ashis first response on contact with a doctor can bequietened down and made to submit to an examinationwould indicate a normal behavioral response andwould generally go against an immediately seriousillness. However, it must be remembered that theexpected response would vary according to the age of the child. Certain observational scales have beendeveloped and validated to identify serious illness in

febrile children. One such scale4

takes six items intoconsideration, viz., quality of cry, reaction to parentstimulation, variation in state of wakefulness and sleep,color, hydration and response to social overtures.

Another recently described5 set of criteria has beenfound to be useful in evaluating children with feverand petechiae. The criteria taken into considerationwere shock (capillary refill time greater than 2 secondsand/or hypotension), irritability (inconsolable crying or

screaming), lethargy (as determined subjectively by thecarer, nursing or medical staff), abnormality of theperipheral blood white cells count (< 5,000 or > 15,000per cumm) and elevation of C-reactive protein (CRP)(>5 mg/l). These criteria were labeled as “ILL- criteria”

Table 1.3: Commonly missed areas in a

complete examination

Area Examples

1. Ear: otoscopic examination - Otitis media2. Genitalia - Torsion testis

3. Anal region - Anal fissure

4. Pupils - Poisoning

5. Blood pressure - Shock, hypertensive

crisis

6. Femoral pulses - Coarctation of aorta

7. Skin covered by - Petechiae

undergarments

Principles of Pediatric and Neonatal Emergencies6

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(irritability, lethargy, low capillary refill) and werefound to have a high sensitivity for identifying childrenwith positive blood cultures. Sensitivity was good evenwhen CRP was not included. It has been shown in

several earlier studies that taken individually thesecriteria have limitations.6-8

Age considerations in assessing a child with feverare also important. Thus, febrile young infants less than3 months age are more likely to have serious illnessthan an older child. Although, it is well known thatthe common viral fever can also cause high fever,generally the risk of bacteremia increases as the degreeof fever increases, but even at > 40°C the risk is only

7 percent.9

CPR IN EMERGENCY DEPARTMENT

Cardiopulmonary resuscitation (CPR) performed in achild who has already had cardiac arrest is a laborintensive, tension producing procedure that more oftenthan not is a frustrating exercise. Chances of intactsurvival are abysmally low.9-13 Thus, it is very impor-

tant to recognize life-threatening illness immediatelyand intervene rapidly. Unlike the methods describedabove for identification of an acutely sick child,recognition of a life-threatening emergency has to bedone quickly. There may be only minimal time to aska focussed history with the details left to a later pointof time. Examination also has to be performed in ashort period of time. It is better to have a structuredapproach. The standard alphabetical order of A forairway, B for breathing and C for circulation is themost appropriate method. These are followed by D fordisability prevention and E for exposure (Table 1.4).

THE DEATH OF A CHILD INTHE EMERGENCY DEPARTMENT

After a child has died, emergency physicians mustrapidly transit from treating the patient to caring for the

survivors. The success of this transition is dependent onmany variables, including the demands of other patientsin the department, the circumstances surrounding thedeath, and the physician’s level of skill, sensitivity, andexperience. Additional demands on the physician mightinclude notifying the proper authorities in the case of violent death or child maltreatment, the discussion of apostmortem examination, and the request for tissue ororgan donation. The physician should speak with thefamily, if at all possible, during resuscitation to establishcontact before informing them of the death of theirchild.14 If the family arrives after the patient ispronounced dead, the physician should inform the

Table 1.4: Pediatric primary survey and

resuscitation measures

A. Airway/Cervical Spine Control

• Assess airway patency

– If patient conscious-maintain position of comfort

– If compromised-position, suction oral airway

– If unmaintainable-oral endotracheal intubation

• Maintain cervical spine in neutral position with

manual immobilization, if head/facial trauma or high-

risk injury mechanism

B. Breathing

• Assess respiratory rate, color, work of breathing,

mental status

• If respiratory effort adequate-administer high-flowsupplemental oxygen

• If respiratory effort inadequate—bag-valve-mask

ventilation with 100 percent oxygen, naso/orogastric

tube, consider intubation

C. Circulation/Hemorrhage Control

• Assess heart rate, pulse quality, color, skin signs,

mental status

• If perfusion adequate-apply cardiac monitor, establish

IV access, direct pressure to bleeding sites• If signs of shock-establish vascular access (IV / IO),

isotonic fluid bolus, baseline laboratory studies,

cardiac monitor, urinary catheter

• If ongoing hemorrhage suspected and continued

signs of shock-blood transfusion and surgical

consultation

D. Disability (Neurologic Status)

• Assess pupillary function, mental status (AVPU)

• If decreased level of consciousness—reassess andoptimize oxygenation, ventilation, circulation.

• If increased ICP suspected—elevate head of bed,

consider mild hyperventilation, neurosurgical

consultation

E. Exposure

• Remove clothing for complete evaluation. Prevent

heat loss with blankets, heat lamps, radiant warmer

AVPU = alertness, response to voice, response to pain,

unresponsive; ICP = intracranial pressure; IO = intraosseous;IV = intravenous

family of the child’s death and of the resuscitative effortsthat were made. It is important that no conflictinginformation be given to the family by the emergencycare team.

Family Presence in Resuscitations

A study of family presence during resuscitation attemptsshowed that 97% would choose to witness it again,76% believed their grieving was made easier, 67%

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Approach to Child in Emergency Department 7

thought their presence was a benefit to the patient, and grieving and reach closure. Prepare the body for viewing


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thought their presence was a benefit to the patient, and100% felt confident that everything possible had beendone to save their family member.15 Although somehealth care providers feel at ease when family members

are present, ED staff, if aware of these statistics, mightunderstand the importance of offering families the optionof being present in these situations, although somemight decline to attend.

Notification of Death

Before declaring death of a child always identifyyourself the family members present. Attempt to have

parents together. Sit down and physically placeyourself in the proximity of the family unless thesituation appears hostile. Always have supportpersonnel with you. Have a scripted sentence that youfeel comfortable with that clearly states that the child“died” or was pronounced dead. An example is,“Despite everything we could do, we couldn’t saveyour child’s life. He/she (use the child’s name here)died a few moments ago.” Avoid language such as

“passed on,” “didn’t make it,” or “they’re with Godnow.” These euphemisms might not be understood byfamily and can create confusion and ultimatelysuspicion of the credibility of the medical staff. If thechild is alive on arrival in the ED, family should beinformed of the patient’s progress frequently or asoften as deemed appropriate and staff is able. Moreimportantly, if the child is expected to die, familyshould be informed that resuscitation efforts areproceeding but that the child is not expected tosurvive.16 Allow grief response and facilitate grief. If you are comfortable, give physical support (hold hands,touch the shoulder) to family members. Stay close andsupportive.

According to a survey,17 after unexpected death of an infant in family interventions that were found usefulin counseling were:

1. Openly accept an individual’s grief reactions.2. Allow the family an opportunity to vocalize their

feelings.

3. Clarify misconceptions.4. Allow the family to hold or to be in the room alone

with their dead infant.5. Provide a private place for the family to gather.6. Provide an explanation for the cause of the death

and help them with funeral arrangements.Allow the family to decide whether to view the

child’s body at this time. Respect their decision if theychoose not to view the body but also realize that seeingtheir child before and after death can help parents begin

grieving and reach closure. Prepare the body for viewi

principles of pediatric and neonatal emergencies, 3rd edition

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